New Data on Migraine and Menopause

Migraine is a common and frequently disabling condition whenever it occurs. As fluctuations in female hormones can have a profound effect on women who are susceptible, one would expect sequelae from the hormonal rollercoaster that accompanies the perimenopause and early menopausal years.

Women are three times more likely to suffer from migraine than men. The cyclical changes in hormone levels are a key trigger, explaining the worsening of migraine commonly see just before, during and after menses.

There are two types of hormonally-sensitive migraine sufferers. Those who experience their headaches during estrogen withdrawal (menses; “off days” of oral contraceptive pills; the lowered hormonal levels of menopause), and those whose migraines worsen when estrogen levels are increased (e.g. after starting oral contraceptive pills or postmenopausal hormone supplementation). This hormonal sensitivity may explain why migraine worsens around time of perimenopause, when estrogen levels fluctuate and decline.

Two-thirds of women’s migraine improves within a couple of years after menopause, although approximately 10% experience worse headaches and approximately 25% notice no change.

Because of the migraine’s schizophrenic reaction to hormones, there is no way of knowing which women will respond positively and which poorly to menopausal hormonal supplementation.

ALL ABOUT MIGRAINE

Modern theory is that migraine is a brain and not a vascular disorder, a disorder of “sensory modulation” with increased sensitivity to sensory input, pain, light, sound, smells and head movement.

A family history of migraines suggests a genetic component. Patients who are genetically predisposed are “triggered” with changes in external or internal environment (sleep alteration, stress, hunger, temperature changes, etc.).

What is a more intimate part of a women’s internal environment than her hormones? Estrogen and progesterone can profoundly alter neurotransmitter (brain enzyme) levels of dopamine, serotonin, etc., effecting the genesis of headaches. Estrogen withdrawal has been shown to alter the levels of several blood proteins, all of which play a role in pain modulation.

The majority of headaches that worsen during peri-menopause are secondary to migraine. Migraines are usually one sided, throbbing, aggravated by movement, light and sound, frequently accompanied by nausea and vomiting, and are of moderate to severe intensity.

MANAGEMENT AND PREVENTION OF MIGRAINE

Treatments may be divided into two categories: Acute (getting rid of the headache once it has started) and preventative.

Acute, first line therapies, other than general lifestyle changes such as relaxation techniques, exercise, and avoiding triggers such as alcohol, may be classified into non-migraine specific and migraine specific.

Aspirin, Tylenol, ibuprofen (“Advil”), Naprosyn (“Aleve”), etc. may be ingested at therapeutic doses (e.g. three-four over-the-counter ibuprofen; two-three “Tylenol Migraine, etc.” at the first hint of a headache. If complete relief is not obtained within 30 minutes, other non-specific medications such as Fiorinal/Fioricet or the narcotic analgesics codeine, Vicodin, etc. should be taken, or the migraineur may proceed directly to “migraine specific” meds such as one of the triptan or ergot medications. The triptans (sumatriptan or Imitrex, rizatriptan or Maxalt, etc.) serve to increase serotonin in the brain and are the mainstay of acute migraine-specific treatment for patients with disabling attacks.

One should be careful, however, with the frequent use of non-specific remedies such as Tylenol, caffeine, codeine and Vicodin, as using such compounds over two or three days per week is probably sufficient to induce chronic “rebound” headaches.

PREVENTION

Someone with frequent headaches (two or more per week) requires a preventative therapy, not additional acute attack treatments. Preventative therapy means that medication should be taken on a daily basis, whether or not there is a migraine; the idea is to reduce the frequency and severity of each attack. Preventative medication may be used in conjunction with acute treatments. These medications include propranolol (Inderal), tricyclic antidepressants (e.g. Elavil, etc.), valproic acid (Depakene), gabapentin (Neurontin) and others. Estrogen as well can be considered under the heading of preventative therapy in women.

HORMONE-SPECIFIC STRATEGIES

Hormonal supplementation does not increase the risk of stroke in patients with migraine. If a woman complains of classical menopausal symptoms as well as worsening migraine, its reasonable to start HRT. A transdermal preparation (patch or cream) may be less likely to exacerbate headaches than oral, especially if the oral is conjugated estrogens (Premarin).

If hormonal supplementation significantly improves menopausal symptoms but causes worsening headaches, a step-wise reduction in dosage (instead of stopping the HRT) may resolve the situation. If this fails, the estrogen type should be changed. There is evidence that converting from conjugated estrogens to pure estradiol, from a synthetic to a bioidentical (especially transdermally) may help.

If alterations in the estrogenic component of HRT are unsuccessful in improving headaches, similar alterations may be made in the progestagenic component, lowering dosage, switching from a progestin-like medroxyprogesterone (Provera) to norethindrone or bioidentical progesterone orally (Prometrium) or vaginally.

Since withdrawal of estrogens can exacerbate migraine (this is seen pre-menopausally in women who have so-called “menstrual migraine,” which is well treated by adding in a small dose of estrogen during the menses), peri- and postmenopausal women are perhaps better treated with continuous, rather than cyclic, HRT. Since the progestagen given along with the estrogen in women with an intact uterus can worsen headaches in some migraineurs, giving the progesterone cyclically (every one-four months) may improve symptoms.

The bottom line? Every woman is an individual, including a woman with migraine. You shouldn’t have to suffer! Have your health care practitioner work out a regimen to fit you.

Reference: “Migraine, Menopause and Beyond” by Miles J. Levy, M.D., and Peter Goadsby, M.D. in Menopause Management (May/June 2003).